Reflections of worth: Exploring self-esteem in caregivers of mentally ill individuals

INTRODUCTION

Self-esteem is an elementary aspect of psycho-social health, reflecting how individuals perceive their worth and value. It influences one’s confidence, motivation, and ability to cope with stress. According to Rosenberg, self-esteem refers to an individual’s favorable or unfavorable assessment of their own, shaped by experiences, social interactions, and achievements.¹ High self-esteem is associated with better resilience and coping strategies, while low self-esteem leads to inadequacy, depressive feelings, and anxiety. Caregivers with low self-esteem may find it harder to seek support, manage stress, and maintain the quality of care they provide to their loved ones. Caregivers often bear a significant psychological and emotional burden, which can impact their mental well-being and self-esteem.²

Clinical and consulting psychologist Russell F Fuller lists the following as effects of low self-esteem: anxiousness, diminished stress threshold, loneliness, increased risk of depression, relationship issues, sexual dysfunction, poor performance in school and work, underachievement, and high rate of substance abuse.³ According to a survey, 1 in 8 people, or over 970 million people globally, suffer from a mental health issue. In 2017, 197 million people in India experienced mental health issues. Of them, 44.9 million suffered from anxiety, and 45.7 million had depression. It is anticipated that one member of every four families may experience a behavioral or mental health issue.⁴ According to National Institute of Mental Health and Neuro Sciences 2016 National Mental Health Survey, between 70% and 80% of Indians with mental illnesses did not receive treatment. Thus, 8% of the population suffered from mental illness. The prevalence of mental health issues is rising in Karnataka, along with the burden that falls on family members and caregivers.⁵

Research has shown that caregivers of mentally ill patients may experience increased stress, low social support, social isolation, financial strain, and stigma. These factors can lead to lower self-esteem, which in turn affects their ability to provide effective care.^6-11 Our observation during professional life is that family members bear an increasingly heavy load. They deal with stress, money issues, and social stigma. Given the increasing recognition of the mental health challenges faced by caregivers, the study aimed to assess self-esteem levels of caregivers of mentally ill clients and explore the connection with self-esteem and characteristics such as age, education, and employment status. By identifying the factors that contribute to low self-esteem, the study seeks to provide insight into the development of support systems and interventions tailored to the needs of caregivers.

MATERIAL AND METHODS

A cross-sectional descriptive survey was employed to assess the level of self-esteem in caregivers. The study was carried out at Father Muller Medical College Hospital, Mangaluru. It is a multi-specialty hospital with a dedicated mental health center. The study population comprised family caregivers of mentally ill individuals who were either admitted to the psychiatry ward or visited the outpatient department. Caregivers were defined as family members who played a significant role in the daily care and support of the patient. A sample size of 120 caregivers was determined using the purposive method of sampling. The size of the sample was calculated based on a previous study,⁸ with a 95% confidence level and a 10% potential attrition rate. Inclusion criteria included: Age 18 years and above, having provided care for 6 months minimum, and living with and being actively involved in caring for individuals with mental illnesses. Caregivers with a history of any mental illness, non-family members providing care (e.g., professional caregivers), and caregivers with physical disabilities that could affect their ability to respond to the study tools were excluded. The study tool consisted of two parts: A baseline proforma and Rosenberg’s Self-esteem Scale. Baseline proforma comprised of clinical diagnosis, length of illness, number of prior psychiatric hospitalizations, age, gender, marital status, education, family type, employment, economic status, and relation to patient. The self-esteem scale of Rosenberg was utilized. The tool’s internal consistency was tested, and the reliability was found to be 0.88. It is a 10-item scale that assesses a person’s self-worth by considering negative and positive perceptions. It is a 4-point Likert scale, with responses ranging from strongly agree to strongly disagree for all items. The scale ranges from 0 to 30. A score of 30 is the highest. The level of self-esteem was scored as follows: 0-14 is low, 15–25 is normal, and 26-30 is high.

The Institutional Ethical Committee issued ethical clearance (FMIEC/CCM/122/2023). The study was registered under the Clinical Trial Registry of India. (CTRI/2023/11/060156). All participants provided written informed consent, which ensured privacy and participation on their own. Subjects received assurances that their input would be kept anonymous while being utilized exclusively for the purpose of research. Data collected from April 3 to April 30, 2024. Permission from the institution authority was obtained before the data collection. The caregivers who met the inclusion criteria were selected, and tools were administered. Explanations of the research were given. Data were analyzed on SPSS software (version 22.0). Descriptive statistics, including frequency, percentage, mean, and standard deviation, were used to summarize demographic data and self-esteem level. Inferential statistics, specifically Fisher’s exact test and Chi-square test, were used for association with self-esteem levels and study attributes, considering a p-value of <0.05.

RESULTS

Table 1 includes data regarding relevant socio-demographic details of mentally ill individuals’ caregivers. The mean and SD age of participants were 44.6±15.2. About 60.8% of the subjects were married. More than half of them (55.8%) were males. 40.0% of them had higher secondary education, 81.3% belonged to a nuclear family, and 62.5% were unemployed. Moreover, 58.3% of the subjects were below the poverty line. The majority of the caregivers were parents (30%,) followed by children (26%), spouses (23.3%), and other relatives (10.0%).

Table 2 includes the clinical variables of mentally ill patients. Nearly 29.2% of the mentally ill patients were diagnosed with mood disorder, delusional disorder (25.8%), schizoaffective disorder (20%), schizophrenia (15.8%), and unspecified non-organic psychosis (9.2%). Almost half (49.2%) were suffering from illness for less than 5 years, and about 29.2% for more than 10 years. Most (82.5%) of the mentally ill patients had no previous admission or had been admitted less than two times.

Table 3 shows that the majority (74.2%) had normal, about 25.8% had low levels, and none of the study samples had high levels of self-esteem. The mean ± SD self-esteem of the caregivers of mentally ill patients was 15.79 ± 2.32, the median was 15, and the mean percentage was 52.3%. Table 4 details the connection between self-esteem with baseline characteristics. The median value of self-esteem obtained in the study was 15; it was used to assess association. Self-esteem did not significantly associate with baseline attributes such as sex, age, marital status, educational level, family type, employment status, relationship with patient, clinical diagnosis, duration of illness, number of previous hospitalizations, at a 0.05 significance level.

DISCUSSION

Age distribution among caregivers for mentally ill patients in the current study was 44.6±15.2. Males made up 55.8% of the subjects. The percentage of married subjects was about 60.8%. Many (40%) had completed higher secondary education. Nearly 81.3% of the participants were members of nuclear families. Most (75%) were unemployed, and 70% were below the poverty line. Additionally, 30% were parents, 26% were children, and 23% were spouses. Of the subjects, nearly half (49.2%) had been suffering from illness for fewer than 5 years. Most of the subjects (82.5%) had no previous admission or had been admitted less than two times in a psychiatric institution in the past.

Whereas, in a similar study among caregivers of Indian schizophrenic patients, the majority were aged above 35. About half of the patients were males. Many were married and employed. About 52% were parents, and the majority of them belonged to nuclear families.¹² However, in a related study, the majority of caregivers for mentally ill patients were between the ages of 32-38 years. Men comprised the majority of caregivers (61.9%). About 69% of the patients had a mental disorder for longer than five years. Approximately 44.3% of them had previously been hospitalized; 95.34% of them had fewer than or equivalent to five hospital stays. Lastly, 96% of the patients were on medication alone.¹³

In a study done in a psychiatry clinic at Jimma University Specialized Hospital in Ethiopia, 70.38% of the participants were men, and 67.77% of them were married. The caregivers’ average age was 37.8 (±13.9) years. Roughly 15.4% of people lacked literacy, while 30.09% had completed secondary school. Parents (25.12%) and other relatives (25.59%) made up the bulk of the caregivers, and most of them (81.04%) shared a home with the patients. Roughly 36.26% were farmers.¹⁴

A study conducted in China found that 53.3±13.5 was the average age of the caregivers, and 76% of them were married. The patient was diagnosed with depression (34.6%), Bipolar Affective Disorders (BPAD) (18.5%), and schizophrenia (46.8%). Moreover, 55% of the patients had previously been admitted to the hospital.¹⁵ The current study’s findings are in par with those of a related investigation conducted at Udupi taluk. Most caregivers (55.6%) were between the ages of 31-50. Nearly 38.4% of them were men, and the majority (80.9%) were married. Of these, around 33.4% possessed a university degree. Parents (20.3%) and spouses (30%) made up most of the caregivers. Of them, 41.6% earned more than 10,000 Indian rupees a month.⁸ The changes in the setting, cultural practices, and characteristics of caregivers might have led to changes in the findings.

Caregivers who take care of mentally ill people must have adequate self-esteem. It is important to deal with the frustration that comes from dealing with psychological conflicts and societal norms. The current study revealed that none had high self-esteem, while the majority of subjects (74.2%) had normal self-esteem and 25.8% had a low level of self-esteem. Results of the study were congruent with research at KMC Hospital in Manipal, where the majority of participants (68.3%) had normal self-esteem, followed by low self-esteem (30.2%) and high self-esteem (1.6%).¹⁶ The current study’s mean self-esteem of 15.98±2.86 is consistent with another study conducted at Central India Institute of Mental Health and Neuro Sciences Chhattisgarh.¹⁰ The current study’s outcome defies that of earlier research of a similar nature conducted in Faridkot¹⁷ and South-West Nigeria,¹⁸ where most participants (64%) exhibited a low level of self-esteem. Findings state that it is crucial to take appropriate measures to enhance the self-esteem of the caregivers, as it ranges from normal to low, and very few had a high level of self-esteem.

In the current study, the research hypothesis was rejected because, at a 0.05 significance level, no association was found with self-esteem and baseline variables. The study findings were on par with a similar study done at Mangaluru, which stated no association with expressed emotions and characteristics at a 0.05 level of significance.¹⁹ In contrast, a study had an association with occupation and caregivers’ burden scores at a 0.05 level of significance.⁷ More studies employing a huge sample are required to support the finding.

CONCLUSION

Because caring for individuals with mental illness involves additional obligations and demands a lot of their time, energy, and attention, caregivers’ quality of life is typically poor. High levels of stress are caused by this added obligation, and caregivers might not have the right coping skills. As per the American Psychological Association, experiencing strong self-worth is crucial for good emotional health and well-being. The study found that most of the caregivers had a normal level of self-esteem. More research and clinical trials are required in this field to achieve high self-esteem among the caregivers of mentally ill patients. Our study results provide a basis for planning and implementing needed interventions and policies for patients to promote the self-esteem of caregivers of mentally ill clients, thereby enhancing life quality.